Chronic pain is a major concern in the veterans’ health care arena. Forty percent of opioid prescriptions are written to treat CNCP by primary care providers although opioid use poses potential health risks (Okie, 2010). Patients prescribed opioid therapy are at risk for accidental death and overdose (Kissin, 2013), requiring a need for new opioid prescribing practices and policies. Ninety percent of deaths related to poisoning are caused by drug overdoses (Okie, 2010), and to date have increased greater than 400%
(Zolot, 2017). Appraisal of high-quality based studies identifies evidence-based best practices for managing CNCP in veterans. In this section, the 16 studies that met the inclusion criteria for this systematic review (Appendix C) were analyzed and synthesized. The findings are presented in this section.
Findings and Implications
This analysis and synthesis for this systematic review was completed with the 16 research papers that met the inclusion criteria. The quality of evidence was graded using JBI-SR grading chart (Appendix B). The Grade A assessment represents a strong recommendation with high-quality evidence likely to yield high-quality outcomes. The Grade B assessment indicates a low recommendation providing evidence likely to support low-quality outcomes. For this review, evidence-based management strategies for CNCP included yoga, botulinum toxin injections, chondroitin injections, peer support, and behavioral therapies. Overall, most of the evidence indicates opioids pose multiple health
risks and little evidence supports the efficacy and safety profile for opioid management strategies for CNCP (Appendix D).
Education and Knowledge about Therapies
Four studies addressed the effects that knowledge and education had on beliefs and behaviors about chronic pain management and preferred treatment options. Three of the studies provided evidence of adequate quality to provide a positive outcome (Grade A), and one provided evidence of lesser quality to provide a positive outcome (Grade B).
Frank et al. (2015) reviewed treatment modalities used by providers (n= 159) who attended or presented during Specialty Care Access Network-Extension for Community Healthcare Outcome (SCAN-ECHO) sessions for treating patients (n = 22,545) with chronic pain. Providers attending or presenting for SCAN-ECHO sessions were less likely to prescribe opioids for CNCP and frequently chose physical medicine services instead of pain medications. Unanticipated limitations consisted of multiple articles identifying opioids as not preferred for CNCP and few evidence-based studies identifying alternative pain management options to opioids.
Cosio and Lin (2015) completed a quasi-experimental study (Grade B) using a pre- and posttest to identify if veterans (n = 103) receiving 12 weeks of pain education are likely to choose complementary alternative medicine (CAM) and therapies over opioid therapy. The findings indicated a significant difference in the use of CAM therapies for veterans receiving pain education about CAM therapies. Chapman et al.
(2010) completed a secondary analysis evaluating guidelines for chronic pain
management developed by interdisciplinary research experts to assess veterans prescribed
opioids for 6 months or longer to determine the benefits and the harm of opioid use in chronic pain management. The experts indicated that scientific evidence lagged behind the growing use of opioids and the need for a strong evidence base to guide chronic pain management limiting opioid use because the risks of opioid use outweigh the benefits.
Chapman et al. (2010) identified significant difference between the beliefs and behaviors of patients and providers who did not receive opioid and CAM therapy education and those who did receive education.
Denneson et al. (2011) completed a secondary analysis of systematic reviews to evaluate the use of CAM therapies among veterans with previous CAM use (n = 401) compared with veterans having no previous CAM use. The results revealed that veterans with previous CAM use are likely to use CAM therapies because of previous positive effects. Providing education about CNCP, opioid therapy, alternatives to opioids, and prior pain care knowledge influences beliefs and behaviors concerning CNCP
management. Two studies identified CAM as therapies of choice for patients and providers after they gained knowledge about the efficacy of these therapies. Providers were less likely to choose opioids as the first line of treatment after attending or presenting educational pain presentations during SCAN-ECHO sessions. Providing knowledge about alternative pain management options allows patients and providers to choose pain management options with fewer adverse events.
Opioid Therapies
In five of the studies, researchers evaluated the effects opioid use has on pain relief and behaviors of those treated for CNCP over time. Four of these studies provided
lower quality evidence supporting positive outcomes (Grade B), and one provided high quality evidence supporting positive outcomes (Grade A). Naliboff et al. (2011), used a RCT of 135 veterans for 12 months (94% males and 74% with musculoskeletal pain) and compared patient responses to escalating opioid dosages withhold-the-line opioid dosing for chronic pain management and found a significant risk of opioid misuse with no statistically significant difference in primary outcomes. Patients receiving increased opioid dosages experienced slightly improved pain control compared with veterans receiving non-escalating doses of opioids. Morasco, Cavanagh, Gritzner, & Dobscha, (2013) completed a retrospective cohort study for veterans with CNCP (n = 60) comparing the effectiveness of a daily dose of 179 mg of morphine equivalent with a daily dose greater than 180 mg of morphine equivalent, and there were no significant differences in the variables assessed.
Sekhon, Aminjavahery, Davis, Roswarski, & Robinette (2013) completed a retrospective chart review of veterans (n = 800) with CNCP receiving opioid therapy greater than three months or more. According to the records they reviewed, 22.9% of the veterans elicited aberrant behaviors. Simmonds, Finley, Vale, Pugh, & Turner, (2015) conducted a focus group to identify barriers and facilitators to using CAMs for veterans (n = 25) receiving a 50 mg. morphine equivalent daily dose for six months or greater.
The findings indicated that veterans who were prescribed long-term opioid therapy formed pervasive attitudes preventing them from considering CAM therapies rather than opioid therapy.
Morasco, Duckart, & Dobscha (2011) completed a cohort study of veterans (n = 5,814) over 12 months comparing veterans with SUD and veterans without SUD to evaluate adherence to clinical guidelines for long-term opioid therapy use. Only 35% of veterans with SUD received substance abuse treatment and it was found that veterans with SUD require more intense treatment to gain improved pain control and are likely to experience adverse events and poor outcomes. Aberrant behaviors, SUD, development of pervasive attitudes towards using adjunct or alternative therapies, and inability to adhere to opioid clinical guidelines were areas associated with those receiving opioid therapy.
The lack of evidence of opioid therapy providing pain control or improved quality of life indicates that the use of opioids is not a feasible pain management option.
Mental Health Therapies
In five studies researchers addressed the effects mental health therapies have on perceptions about pain intensity, efficacy of pain control, and ability to improve physical functioning. All five studies were grade-A levels of recommendation with high levels of quality evidence. Brinzo, Crenshaw, Thomas, & Sapp (2016) completed a retrospective cohort review of males and females 18 years or older with chronic back pain lasting for at least 12 weeks, and participated in yoga for approximately 4 weeks. It was determined that the effects of yoga on pain has positive effects on pain perception, improved back function, and increased veterans’ sense of wellbeing. Matthias et al. (2015) completed a secondary analysis of RCTs of 20 patients with chronic pain assisted by 10 coaches to evaluate the effectiveness of peer support on chronic pain management, and determined that peer support can be effective in pain management supporting self-efficacy showing
improvements in pain control. Whitten & Stanik-Hutt (2013) completed a qualitative study using CBT with 22 patients with chronic pain to identify the perceptions of pain control outcomes after completing a CBT program over 6 weeks. The findings revealed that selected outcomes were improved for patients treated with opioids for CNCP. Cosio et al. (2015) with a level-B recommendation completed a study using a paired sample t-test, pre- and posttest for veterans (n = 50) receiving acceptance and commitment therapy (ACT) for CNCP to determine the effectiveness of ACT in pain relief. ACT was
identified as an effective treatment for CNCP for veterans and should be considered as a secondary consultative service for CNCP. Cosio (2016) conducted a quasi-experimental study using ACT or CBT using a pre- and post-test for veterans (n = 96) comparing the effectiveness of CBT with ACT for pain relief and decreasing the focus on pain and improving coping skills. Outcomes for mental health pain interventions such as peer support, CBT and ACT were consistent in improving pain perceptions, coping abilities, and improved quality of life. Two of the studies suggested that ACT and CBT be used as adjunct therapies to opioids, suggesting that opioids can be safely used when combined with mental health therapies
Injection Therapies
In two studies researchers identified injection therapies using chondroitin and botulinum for CNCP yielded high levels of evidence with grade-A levels of
recommendations. Singh, Noorbaloochi, MacDonald, & Maxwell (2015) completed a secondary analysis of 43 RCTs including 4962 participants receiving chondroitin and 4148 receiving placebos to compare the effects of pain relief using chondroitin compared
with a placebo over a one to three months duration. The findings identified that
chondroitin use was beneficial yielding an eight-point improvement in pain control which is clinically significant. Singh and Fitzgerald (2010) completed a secondary review of six RCTs of 164 participants with chronic pain to compare the efficacy and safety of
botulinum toxin injections compared with a placebo in treating chronic shoulder pain after 3 to 6 months post injection evaluation. The outcome identified that botulinum toxin injections reduced pain severity with a 95% CI using the 10-point scale and reduction in shoulder disability. Both agents were effective significantly in relieving pain, 8-point improvement on a 10-point scale for chondroitin and a 95% confidence interval on a 10-point scale for botulinum with the duration of 3 to 6 months. Use of injections poses less risk of adverse events and are cost-effective, yielding this method feasible for treating CNCP.
Data from this review will support development of safer pain management policies, protocols and inform safer practice for CNCP. Lack of studies for pain management alternatives to opioids and medications will support the need for future research to identify additional CAM therapies and physical medicine treatments for CNCP. Providing evidence-based information supports the need for legislative mandates to protect communities from overuse of opioids and unsafe prescribing practices.
Improved safer pain care will positively impact the lives of those suffering with chronic pain and their loved ones.
Recommendations
Based on limited evidence to support physical medicine therapies and mental health therapies as effective treatments, it is recommended that further research including RCTs of physical and mental health treatments for CNCP in veterans be completed. This review will provide evidence to gain legislative support to obtain funding to support research and policy development for safer pain care, and increase public safety.
Contributions of the Doctoral Project Team
The project team consisted of the DNP student, a second reviewer, Project Chair and DNP committee. The Chair approved the proposal which was presented to Walden’s IRB and DNP committee for approval. A second reviewer replicated the literature search using identified inclusion and exclusion criteria to prevent bias, and if reviewers were not in agreement with articles for the review, consensus was reached to include or exclude an article. A literature review matrix was developed to organize data, and data were
extracted, and graded using JBIM-SR tools.
Declaration of Conflict of Interest
There were no conflicts of interest by the authors for this project. The purpose of this project was to fulfill the requirement of the Doctor of Nursing Practice degree of Walden University, and identify evidence-based best practice for developing protocols for treating CNCP. No funding or monetary compensation were provided to complete this project.
Implications
Implications for this review supports development of protocols, policy, and procedures for treating CNCP in veterans to provide safer pain management. One hundred million Americans are treated for chronic pain, costing approximately 560
billion annually causing public concern in the United States (Institute of Medicine, 2011).
Providing evidence-based chronic pain care will improve patient outcomes, decrease rising costs of pain management, reduce adverse events from opioid use, and improve veterans’ quality of life.
Strengths and Limitations of the Project
The strength of this project consists of literature from systematic reviews and multiple RCTs consisting of highest evidence-based human research to support development of policies, procedures and protocols of health care. Limitations of the project consist of few articles identifying greater numbers of various forms of CAM methods.
Summary and Conclusions
In conclusion, the evidence suggests that evidence-based best practice for CNCP management consists of non-opioid therapies. Lack of sufficient evidence supporting the use of opioids validates the need to develop protocols and strategies to provide safer chronic pain care. Systematic reviews of RCTs provide the highest level of evidence and are likely to support development of reliable quality improvements in chronic pain care (Higgins & Green, 2011). CAM use for best pain care consists of physical medicine and mental health combined to maximize safe evidence-based CNCP care. Best practices
based on this review are identified as acupuncture, injection therapy, peer support and cognitive behavioral therapies. Sufficient evidence supporting opioid use for CNCP is not available, requiring additional research to identify best practices to support the development of pain protocols and safer pain care.
Section 5: Dissemination Plan